Why French psychiatrists and psychoanalysts are opposed to the diagnostic manual.

Anger and concern about the growing influence of the DSM in France, as well as over a number of related, prominent pharmaceutical scandals here, has culminated in the creation of Stop DSM, a professional and political group that is strongly opposed to the manual’s diagnostic power and what it sees as its negative social consequences. The group, comprising prominent French psychiatrists, psychologists, and psychoanalysts working “across the spectrum” of mental health, has organized a conference next month (its second) that will focus on the DSM’s practical and political consequences. Some panels will cite the diagnostic manual as increasingly a “world problem” while others are slated to invoke alternatives that aim to release France—and much of the rest of the world—from what critics say represents the worst of American psychiatry, including the unwanted but growing “hegemony” of the American Psychiatric Association.

Stop DSM was established two years ago, one of its organizers, Patrick Landman, told me at a planning meeting earlier this week, due to widespread concern about diagnostic trends in French and European psychiatry. In Europe, France has the highest prescription rates for antidepressants among adults. National concern about the widespread use of Ritalin among French children and teens also spiked after the National Consultative Ethics Committee (CCNE) for Life Sciences and Health notedin a report on addiction and on the amount of amphetamine (speed) comprising Ritalin that “the distinction between licit and illicit drugs is not based on any consistent scientific basis.” Excellent studies such as Maurice Corcos’s L’homme selon DSM: Le nouvel ordre psychiatrique(Man According to the DSM: The New Psychiatric Order, 2011) and LaFolie évaluation: Le malaise social contemporain mis à nu (MadnessRating: The Contemporary Social Malaise Exposed, 2011) reach a broad audience here, and the short and powerful collection Pour en finir avec lecarcan du DSM (For an Endto the Yoke of the DSM), associated with StopDSM, is also a bestseller.

You don’t need to look very far to grasp why—or, indeed, to understand why Landman and his colleagues are so concerned. The day after their planning meeting, the New York Times published a balanced op ed by Weill Cornell Medical psychiatrist Richard A. Friedman entitled, “A Call forCaution in the Use of Antipsychotic Drugs.” Abilify, Seroquel, “and other antipsychotic drugs were prescribed to 3.1 million Americans at a cost of $18.2 billion,” Friedman noted, “a 13 percent increase over the previous year, according to the market research firm IMS Health. The number of annual prescriptions for atypical antipsychotics rose [in the U.S.] to 54 million in 2011 from 28 million in 2001,” he continued, “an 93 percent increase, according to IMS Health. One study found that the use of these drugs for indications without federal approval more than doubled from1995 to 2008.” “Until recently,” Friedman concluded, “these drugs were used to treat a few serious psychiatric disorders. But now, unbelievably, these powerful medications are prescribed for conditions as varied as very mild mood disorders, everyday anxiety, insomnia and even mild emotional discomfort.” As this blog noted back in June 2009, Seroquel has evenbeen tested in randomized trials on those with public-speaking anxiety.Stop DSM not only is built on strong academic foundations, but also is well-organized, with a website that translates into up to ten differentlanguages detailing its platform/manifesto, its objectives and activities, a forum for members, and articles from and for contributors detailing concerns and recommendations. Its membership includes prominent, highly acclaimed psychiatrists, psychologists, and psychoanalysts who have found common cause in their opposition to the language, nosology, and effects of the DSM. They are joining the now-global petition againstDSM-5, organized by the Coalition for DSM-5 Reform and supported by numerous mental-health organizations around the world, including 15 divisions of the American Psychological Association. Notes the manifesto of Stop DSM: “The nomenclature of the DSM, on

which [the World Health Organization’s] ICD-10 has been modeled, has progressively become the single and obligatory classificatory reference of “mental disorders” [in France and around the world]:

—in epidemiology;

—in the field of research and scientific publications;

—for social protection systems and insurances;

—in order to collect statistical data for care policy and financing;

—as an unique reference manual in the teaching of psychiatry in medical and psychology schools, for the training of professionals and lecturers in health, social and special education fields;

—[and] finally, for physicians, who, having no other relevant training, prescribe more and more psychotropic drugs, based on questionable diagnostic criteria.”

“With the purpose of responding to specific and distinct requirements,” it continues, “the widespread use of this unique classification becomes a confusion, inadequacy and [source-risk]—especially since the WHO is not empowered to take decisions on scientific research, but instead … should recommend independence, diversity, and promote the coexistence of different approaches.”

“Moreover, far short of scientific rigor, the DSM is based on unambiguously partial conceptions. It neglects … clinical data; multiplies … pathological categories; and lowers the threshold of diagnostic criteria for inclusion, which leads to false-positives and pseudo-outbreaks (as, for example, hyperactivity, bipolar disorder, [and] autism). It is misused for predictive purposes in children and adolescents, taking the risk of harming their development and integration. It also promotes what has become, for a large part of the population, a real addiction to psychotropic drugs.” The manifesto, supported by individual and group signatures, insists that the World Health Organization “stop promoting internationally the ICD-10’s monopoly condition, [derived] from the DSM, … [which is] imposing its dictatorship over … clinical practitioners and researchers that base their practice on other clinical criteria.” It reminds us “that multiple references could coexist, that a single model would not be imposed for all purposes on a simple statistical basis,” and calls on the WHO—and the American Psychiatric Association—“to stop the manipulation of diagnostic categorizations that, under the guise of ‘good practice,’ dictate to practitioners of therapeutic lines for economic or political goals.”“A simplified nomenclature,” concludes Stop DSM, is not “sufficient to respond to the categorizations needed to satisfy social protection.”

Christopher Lane, Ph.D., teaches literature and intellectual history at Northwestern University and is a recent Guggenheim fellow. His work has appeared in the New York Times, Washington Post, Boston Globe, Los Angeles Times, Slate, Chronicle Review, and many other newspapers and periodicals. He is the author of, most recently, The Age of Doubt: Tracing the Roots of Our Religious Uncertainty (Yale, 2011; paperback 2012). His other books include Shyness: How Normal Behavior Became a Sickness (Yale, 2007), winner of the Prescrire Prize for Medical Writing (France), translated into French, Spanish, Japanese, and Korean, with a Danish translation forthcoming. He also writes regularly for the Huffington Post.